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Date run 5/18/2015 10A5:17AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Paget <br /> Run by <br /> Facility Information as of 5/18/2015 <br /> Record Selection Criteria: Facility ID FA0020701 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0017010 New Owner ID <br /> Owner Name Diesel Direct Inc <br /> Owner DBA DIESEL DIRECT WEST <br /> Owner Address 4412 HARLIN DR <br /> SACRAMENTO, CA 95826 <br /> Home Phone Not Specified <br /> Work/Business Phone 888-900-7787 <br /> Mailing Address 74 Maple St <br /> Stoughton, MA 02072 <br /> Care of TIM JOHNSON <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0020701 10453072 <br /> Facility Name Diesel Direct West <br /> Location 3734 Imperial Way Ste E <br /> Stockton, CA 95215 <br /> Phone 916-857-1000 x <br /> Mailing Address 3734 Imperial Way Ste E <br /> Stockton, CA 95215 <br /> Care of Tim Johnson <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail. <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037118 New Account ID. <br /> Mail invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name Diesel Direct West (Circle One) <br /> Account Balance as of 5/18/2015: $0.00 <br /> (Circle One) <br /> Transferto Activellnacive <br /> ProgramlElemeni and Descriptior Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO535942 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN <5 TONS/YR PRO538608 EED001.421 -STACY RIVERA Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535958 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site.andlor project specific,PHSIFHD hourly charges associated with this facility <br /> or activity wili be billed to the party identified as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andbr Standards and State andor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received b <br /> EHD Staff. Date I / Account out: Date 1 9 l 5- ` <br /> COMMENTS Invoice#. <br /> 13 L`# <br /> `11'& <br /> !'& r Com..r,,_ l ' <br />